“SEVERE MENTAL ILLNESS & CONGESTIVE HEART FAILURE OUTCOMES AMONG VETERANS” by Jim Banta UCLA Committee members: Alexander Young, Gerald Kominksi, William Cunningham Ronald Andersen, Chair Special thanks to: SAMHSA – Dissertation Year Award Mental Illness, Research, Education and Clinical Center – West Los Angeles VA Medical Center – Technical Support

Introduction Heart failure is leading cause of death among those greater than 65 years of age. Estimated annual US healthcare costs of $40 to $55 billion. 5 to 25% of medical inpatients have a mental illness. Mentally illness often associated with greater mortality and unfavorable utilization.

Research Questions 1. Is mental illness associated with less primary care? 2. Is mental illness associated with more readmission? 3. Is mental illness associated with more mortality?

Retrospective, cross-sectional design. Selected all inpatient veterans in FY 2001 with congestive heart failure (not just 428.xx). VA National Patient Database: Inpatient (PTF) and outpatient (OPC). Index hospitalization – first CHF admit of the FY. Utilization one year pre index admission and one year post index discharge. METHODS

Used a Behavioral Model Approach. Merged contextual data: County/State of veteran’s primary residence VAMC size, academic affiliation, experience Medical risk adjustment Congestive Heart Failure Index Elixhauser method – 22 of 30 dummy variables METHODS

Hierarchical categorizing of mental illness (ICD-9 CM codes of 292 to 316) Dementia Severe Mental Illness Schizophrenia/PTSD/Bi-Polar Depression Anxiety Other mental illness (excludes substance abuse) METHODS

Descriptive statistics (n=15,685) RESULTS % of total subjects Mean Age Died during study No mental illness 68% 70 12% Dementia 8% 77 21% SMI 6% 63 12% Depression 12% 68 13% Anxiety 3% 70 15%

ODDS of Primary Care RESULTS No Inpatient (n=10,861) Inpatient (n=4,824) Dementia *** SMI 2.2*** 0.9 Depression 2.4*** 1.0 Anxiety 4.4*** 1.7 * p<0.05, ** p<0.01, *** p<0.001

ODDS of Readmission (within one year) RESULTS No utilization in Model (n=14,760) Utilization in model (n=14,760) Dementia SMI 1.1 Depression 1.2** Anxiety 1.2* * p<0.05, ** p<0.01, *** p<0.001

ODDS of Mortality (adjusting for utilization) RESULTS Died in index hospitalization (n=15,685) Died after discharge (n=14,760) Dementia 1.5** 1.5*** SMI 1.3 Depression Anxiety * * p<0.05, ** p<0.01, *** p<0.001

Among inpatient veterans with heart failure: Veterans with a mental illness are MORE likely to get primary care (except for those with dementia). Veterans with depression and anxiety are MORE likely to be readmitted. Veterans with dementia are MORE likely to die. SUMMARY

Mental illness plays limited role in heart failure outcomes within the VA system: suggests that quality care is being provided to a vulnerable population. Greater emphasis on primary care may decrease mortality among those with dementia. Greater monitoring after discharge may reduce readmission and mortality among those with depression or anxiety Earlier targeting of veterans with severe mental illness may delay hospitalization for heart failure. SIGNIFICANCE